Student Learning Survey

Please complete the following survey to provide details about your abilities related to school/learning.

This is an optional survey available to ANY student who feels they might have difficulties with certain aspects of school, learning, or course work.

Students who have prior documentation of a specific learning disability (IEP, 504 Plan) may also acknowledge that here so that they can be assisted with submitting documentation and gaining access to appropriate accommodations.

When you submit this form, it will not automatically collect personal details like name and email address. You must provide this information yourself using the survey items.

1. Please enter your full name. *This question is required.

2. Please enter your date of birth in the following format (mm/dd/yyyy). *This question is required. This question requires a valid date format of MM/DD/YYYY.

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3. Please enter your email address (Your RichmondCC student email is preferred). *This question is required. This question requires a valid email address.

4. Please enter your telephone number *This question is required.

5. Have you received any accommodations/modifications while attending school in the past? These could include modified assignments, extended time, having items read-aloud, small group testing, etc. *This question is required.

6. Can you provide documentation of specific learning disabilities? Examples of documentation could include a primary doctor referral, an evaluation from a psychiatrist, etc. *This question is required.

7. Please select one or more of the options shown below that you feel to be the most challenging for you in terms of learning/school. *This question is required.

8. Please provide a brief description of any struggles you have had with school/learning in the past (Maximum 200 words). *This question is required.

9. Are you interested in learning more about tools and resources that are available to you? These tools and resources do not require any evaluation or documentation. *This question is required.